A missing persons report on a man who was “delirious and confused” when he left Canberra’s Calvary Hospital was delayed because of a typo in an email address, a coronial inquest into the man’s death has heard.
At the beginning of the inquest into the death of 61-year-old Tahadesse Kahsai, the court was told his family wants answers about how he was allowed to leave the hospital and subsequent search efforts.
Mr Kahsai was admitted to Calvary suffering from alcohol withdrawal on December 26, 2015, and walked out four days later, never to be seen alive again.
The ACT Coroners Court heard the inquest would focus on the circumstances around Mr Kahsai’s departure from the hospital, the process of notifying police he was missing and the appropriateness of the searches carried out.
The court was told on the morning Mr Kahsai walked out of the hospital one nurse observed he was delirious and confused.
The court heard a wardsman had a brief conversation with Mr Kahsai outside the hospital but did not have any immediate concerns for him.
Later that morning another staff member called police to file a missing persons report but was advised a form needed to be lodged via email.
A typo in the email address meant the form was never received by police.
The court heard the error was only realised the following day when inquiries were made about the status of the search, and the delay in reporting meant police assumed Mr Kahsai was no longer in the vicinity of the hospital.
A patrol was sent to his home and police spoke to a neighbour who advised he thought Mr Kahsai had returned home the night before.
Police searched the home but there was no sign of Mr Kahsai.
Coronial investigator Senior Constable Matthew Callaghan told the court he had made seven findings including:
- An initial phone call from staff to police advising Mr Kahsai was missing was not recorded on the police database
- Police waited for a missing persons report to be emailed but an error in the address meant it never arrived
- Misinformation from a neighbour impacted the search area
- Calvary Hospital provided inconsistent information about Mr Kahsai’s condition
Body found less than 2km from hospital
The court was told the police officer leading the investigation was not on duty for a period of nine days after Mr Kahsai went missing, resulting in a lack of progress.
The court heard it was not until nearly a month later a search of bushland around the hospital was conducted but that failed to locate Mr Kahsai.
Search crews focused on areas that would provide shelter and not open areas.
Mr Kahsai’s body was eventually found 1.9 kilometres in a straight line from the hospital by two students conducting environmental monitoring in the area on April 2, 2016.
Senior Constable Callaghan made recommendations for the coroner to consider including:
- Police create a case file no matter how the notification is received
- Police record attempts of handover on the case file
- Missing patient reports be completed by a treating doctor
- Introducing different-coloured ID bands indicating a patient’s risk of absconding
The lawyer representing Mr Kahsai’s family told the court they were not seeking vengeance but wanted answers about what happened and assurances it would not happen again.
Seventeen witnesses are listed to give evidence over the next four days.